Healthcare Provider Details

I. General information

NPI: 1548282601
Provider Name (Legal Business Name): CHARLES CRAIG STAFFORD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 02/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 HARRODSBURG RD BLDG A STE 450
LEXINGTON KY
40504-3751
US

IV. Provider business mailing address

1451 HARRODSBURG RD STE D304
LEXINGTON KY
40504-3773
US

V. Phone/Fax

Practice location:
  • Phone: 859-373-0215
  • Fax: 859-373-0235
Mailing address:
  • Phone: 859-977-4000
  • Fax: 859-977-5100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number24728
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: